HORMONE RESEARCH
Horm Res 2008;70:294-299 DOI: 10.1159/000157876
Received: August 8, 2007 Accepted: January 7, 2008 Published online: September 30, 2008
Usefulness of Transcription Factors Ad4BP/SF-1 and DAX-1 as Immunohistologic Markers for Diagnosis of Advanced Adrenocortical Carcinoma
Tomoyoshi Kaneko Yoshiyuki Kojima Yukihiro Umemoto Shoichi Sasaki Yutaro Hayashi Kenjiro Kohri
Department of Nephro-Urology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
Key Words
Adrenocortical cancer, diagnosis · Immunohistochemistry · Transcription factors · Ad4BP/SF-1 · DAX-1
Abstract
Background: We examined the expressions of Ad4BP/SF-1 and DAX-1 in primary and metastatic lesions of advanced adrenocortical carcinoma with normal hormonal findings by immunohistochemistry and discussed their usefulness as immunohistochemical markers for diagnosis. Patients and Methods: Four patients (average age 54.3 ± 3.9) with retro- peritoneal and metastatic tumors were enrolled in this study. All patients had normal hormonal findings. Ad4BP/SF-1 and DAX-1 underwent immunohistochemical study using nee- dle biopsy specimens from the retroperitoneal tumor or metastatic tumor of these patients to diagnose primary adrenocortical carcinoma. Results: Immunoreactivity for Ad4BP/SF-1 and DAX-1 indicated that it was localized exclu- sively in the nuclei. Ad4BP/SF-1 immunoreactivity was ob- served in the carcinoma cells of 2 patients, but not in the others, whereas DAX-1 immunoreactivity was observed in the carcinoma cells of all 4 patients. Conclusion: The expres- sions of Ad4BP/SF-1 and DAX-1 are considered essential to maintain the biological characteristics of adrenocortical cells even without abnormal hormonal findings or even after malignant transformation and metastasis. These markers are
useful to distinguish other retroperitoneal tumors, especial- ly in patients with bulky tumors, and to diagnose the meta- static site of origin as adrenocortical carcinoma in patients clinically presenting with widespread metastasis.
Copyright @ 2008 S. Karger AG, Basel
Introduction
Adrenocortical carcinoma is rare, accounting for 0.02% of all annual cancers reported [1]. Since it is a very aggressive tumor, early diagnosis is desirable; however, there is no specific tumor marker or characteristic radio- photographic findings, so it is difficult to determine the diagnosis of adrenocortical carcinoma or other retroper- itoneal tumors, especially when evaluating patients with bulky tumors in the retroperitoneal space or patients clinically presenting with widespread metastasis of un- known primary lesion [2]. Even if a biopsy is performed for a retroperitoneal huge mass or metastatic tumor, bi- opsy specimens are sometimes not helpful to diagnose the origin accurately, because the pathological findings of advanced adrenocortical carcinoma are not usually specific [3-5].
Ad4BP (NR5A1: Ad4 binding protein, also known as steroidogenic factor-1; SF-1) and DAX-1 (NR0B1: dosage- sensitive sex reversal, adrenal hypoplasia congenita
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| Case | Age | Gender | Chief complaint | Tumor size cm | Hormonal findings | Metastasis site | ||
|---|---|---|---|---|---|---|---|---|
| ACTH, pg/ml normal: 8.0-55.0 | Cortisol, µg/dl normal: 3.0-16.0 | Aldosterone, pg/ml normal: 30.0-240.0 | ||||||
| 1 | 49 | female | postmenopausal vaginal bleeding | 12×10×10 | 47.8 | 16.0 | 72.0 | left, internal iliac lymph node |
| 2 | 52 | female | left inguinal pain | 18×10×10 | 14.8 | 10.3 | 130.0 | left, iliac bone |
| 3 | 57 | female | left back pain | 16×10×11 | 38.0 | 13.0 | 60.0 | left, 8th and 9th ribs |
| 4 | 58 | male | none | 14×14×13 | 17.8 | 5.4 | 100.0 | liver |
(AHC), critical region on the Y chromosome gene 1) are orphan members of the nuclear hormone receptor super- family of transcription factors [6]. They are expressed in several endocrine tissues of mice and rats, including the adrenal cortex, pituitary, hypothalamus and gonads, and play a critical role in adrenal development, gonadal func- tion and steroidogenesis. They are considered to play important roles in embryonic differentiation and the biological function of primary steroidogenic tissues, in- cluding the adrenal cortex. It has been reported that Ad4BP/SF-1 and DAX-1 immunoreactivity was observed in human pituitary, adrenal, ovarian and testicular dis- orders [2,7-11].
In this study, we examined the expressions of Ad4BP/ SF-1 and DAX-1 in the primary or metastatic lesion of advanced adrenocortical carcinoma by immunohisto- chemistry, and discussed the usefulness of Ad4BP/SF-1 and DAX-1 expressions as immunohistochemical mark- ers for the diagnosis of advanced adrenocortical carci- noma with normal hormonal findings, using needle bi- opsy specimens.
Patients and Methods
Patients
From 1997 to 2005, we treated 4 patients (1 man and 3 women, 49-59 years old, average 54.3 + 3.9) with advanced adrenocorti- cal carcinoma (stage IV). The clinical descriptions of the 4 pa- tients are presented in table 1.
Patient 1, a 49-year-old woman, presented with postmeno- pausal vaginal bleeding. Abdominal CT demonstrated a 12 × 10 × 10 cm mass with a necrotic lesion in the left retroperitoneal space (fig. la). Left internal iliac lymph node swelling and a uter- ine tumor were also detected. Although she was diagnosed with uterine cancer, biopsy specimens of the retroperitoneal tumor were obtained using a 20-gauge biopsy needle under CT guid- ance. Patient 2, a 52-year-old woman, presented with left inguinal pain and swelling. CT showed a left 18 x 10 × 10 cm mass with a necrotic lesion of the mass in the right retroperitoneal space (fig. 1b). A large mass was also visible in the left iliac bone (fig. 1c). Biopsy specimens of the left iliac tumor were obtained using a 20- gauge biopsy needle under ultrasound guidance. Patient 3, a 57- year-old woman, presented with left back pain. CT showed a left 16 × 10 × 11 retroperitoneal tumor and multiple rib metastases. Open biopsy was performed for the left retroperitoneal tumor. Patient 4, a 59-year-old man, had no symptoms, but a right 14 × 14 × 13 cm retroperitoneal tumor and liver tumor were inciden- tally found by CT during his complete medical checkup. Biopsy
| Case | Biopsy site | Ad4BP/SF-1 | DAX-1 | Therapy | Prognosis |
|---|---|---|---|---|---|
| 1 | adrenal | +++ | +++ | op'-DDD | alive for 18 months |
| 2 | bone | + | +++ | op'-DDD | alive for 17 months |
| 3 | adrenal | – | ++ | none | died of disease after 2 months |
| 4 | adrenal | – | ++ | op'-DDD | died of disease after 10 months |
The immunoactivity of Ad4BP/SF-1 and DAX-1 was graded as follows: +++ = >75% positive cells, ++ = 51- 75% positive cells, + = 1-50 positive cells, and - = no positive cells.
specimens of the retroperitoneal tumor were obtained using a 20- gauge biopsy needle under CT guidance.
Serum hormone levels (ACTH, cortisol, aldosterone, catechol- amine) were normal in all patients. CT showed necrotic lesions in 4 cases and tumor calcification in 2 cases. Serum hormone levels and CT and MRI findings were not crucial for the diagnosis of adrenocortical carcinoma.
As controls, 3 patients (2 men and 1 woman, 45-62 years old, average 55.7 ± 4.9) with large retroperitoneal tumor with or without metastasis, who were finally diagnosed with renal cell carcinoma, were also enrolled in this study. One male patient without metastasis had a 9 x 5 x 5 cm retroperitoneal tumor, and another male patient and a female patient with lung and bone metastases had a 10 x 9 x 9 cm and an 11 × 10 × 9 cm retro- peritoneal tumor, respectively.
The specimens were fixed in 10% paraformaldehyde for 24 h immediately after obtaining biopsy specimens. After fixation, the specimens were embedded in paraffin wax to evaluate the expres- sions of Ad4BP/SF-1 and DAX-1.
Immunohistochemistry
Paraffin sections (5 um thick) were mounted on slides, de- waxed, and rehydrated, and endogenous perioxidase was blocked using 3% (v/v) hydrogen peroxidase in PBS for 5 min. After wash- ing in water, the sections were subjected to microwave antigen retrieval in 0.01 M citrate buffer; thereafter, they were washed in PBS and blocked with a blocking solution containing 5% bovine serum albumin in PBS for 30 min. They were subsequently incu- bated overnight at 4℃ with primary antibodies diluted appropri- ately with blocking solution. Rabbit anti-Ad4BP/SF-1 and guinea pig anti-DAX-1 were used as the primary antibody [11]. Biotinyl- ated anti-rabbit IgG (Nichirei Co., Tokyo, Japan) and anti-guinea pig IgG (Vector Laboratories, Inc., Burlingame, Calif., USA) were used as the secondary antibody. Antibody-antigen complexes were detected by the streptavidin-biotin-peroxidase or alkaline phosphatase method using a Histofine kit (Nichirei Co., Tokyo, Japan).
Immunoactivity was graded as follows: +++ = >75% positive cells; ++ = 51-75% positive cells; + = 1-50% positive cells; - = no positive cells.
Results
Pathological findings using needle biopsy specimens show the proliferation of eosinophilic and atypical cells with alveolar and solid patterns associated with mitosis, but it is difficult to diagnose primary adrenocortical car- cinoma. We examined the expressions of Ad4BP/SF-1 and DAX-1 in biopsy specimens from 4 patients to distin- guish from other retroperitoneal tumors and to diagnose adrenocortical carcinoma. Immunoreactivity for Ad4BP/ SF-1 and DAX-1 indicated that it was localized exclusive- ly in the nuclei. Ad4BP/SF-1 immunoreactivity was ob- served in carcinoma cells of patients 1 and 2, but not in the others. On the other hand, DAX-1 immunoreactivity was observed in carcinoma cells of all 4 patients (fig. 2; table 2). Although we also examined the expression of Ad4BP/SF-1 and DAX-1 in 3 patients with large retro- peritoneal tumor with or without metastasis, who were finally diagnosed with renal cell carcinoma, no immuno- reactivity was observed in carcinoma cells of these pa- tients (fig. 2).
All patients, except patient 3, were treated with op’- DDD immediately after the diagnosis of adrenocortical carcinoma. Patients 1 and 2 survived for 18 and 17 months, respectively, after diagnosis, whereas patients 3 and 4 died 2 and 10 months, respectively, after diagnosis (table 2).
Discussion
Adrenocortical carcinoma is a heterogeneous malig- nancy with incompletely understood pathogenesis and is a very aggressive tumor. The overall 5-year survival rate after diagnosis is 15-47%. For stage IV tumors, the ap- proximate 5-year survival is 0% [12].
| Patient 1 | Patient 2 | Patient 3 | Patient 4 | Negative control |
|---|---|---|---|---|
| & eosin Hematoxylin | ||||
| Ad4BP/SF-1 | ||||
| DAX-1 |
Fig. 2. Expressions of Ad4BP/SF-1 and DAX-1 in the specimens of 4 patients and 1 patient with renal cell carcinoma (negative con- trol). Immunohistochemical analyses were performed on 5-pm-
thick sections from the testis, as described in Materials and Meth- ods. Immunoreactivity for Ad4BP/SF-1 and DAX-1 indicated that it was localized exclusively in the nuclei. ×400.
It is very difficult to determine adrenocortical carci- noma before treatment in patients with bulky tumors in the retroperitoneal space or patients clinically presenting with widespread metastasis of unknown primary lesion [2]. Once a retroperitoneal tumor is detected, it is impor- tant to make a differential diagnosis between adrenocor- tical carcinoma and other retroperitoneal tumors, includ- ing sarcoma, renal cell carcinoma or hepatocellular carci- noma [13], as well as between adrenocortical carcinoma and metastatic tumors, including carcinoma of the uter- us, large cell carcinoma of the lung, malignant pheochro- mocytoma or malignant melanoma [13]. It is well known that the biological features present in non-neoplastic ad- renocortical cells, including steroidogenic enzymes, are altered through malignant transformation [14]. Although some adrenocortical neoplasms produce cortisol, and then androgen, estrogen, or aldosterone [15], others are hormone non-functional, which makes it difficult to iden- tify specific adrenocortical tumor markers. In all our cas- es, however, hormone levels were normal.
Systemic chemotherapy, including op’-DDD, is gener- ally the first-choice treatment for patients with advanced adrenocortical carcinoma [12]. The diagnosis is very im- portant because op’-DDD treatment results in a small but
significant increase in the mean survival time [16, 17]. Although early diagnosis using small biopsy specimens is necessary to determine the treatment method, histo- pathologic diagnosis of adrenocortical carcinoma at pri- mary and metastatic sites can be difficult, especially in patients without adrenocortical hormonal abnormality [3, 5]. Immunohistochemical studies have been used to identify the differentiation pattern in morphologically undifferentiated tumors [18]. Cytokeratin, vimentin, D11 and p53 are potential immunohistologic markers of ad- renocortical carcinoma. Although the most common im- munoprofile for adrenocortical carcinoma is positive staining of vimentin, immunohistologic markers are limited in characterizing adrenocortical carcinoma tis- sue [18] because some neoplasms show positive vimentin staining. On the other hand, Ad4BP/SF-1 and DAX-1 are adrenocortical steroidogenesis-related genes that seem to reflect the origin of adrenocortical tumor cells regardless of their independence of hormone production; therefore, they might be more useful immunohistochemical mark- ers for adrenocortical carcinoma than previously report- ed markers.
Ad4BP/SF-1 was originally identified as a steroidgen- ic, tissue-specific transcription factor implicated in the
expression of the steroidogenic CYP gene encoding cyto- chrome P450s [19]. The expression of Ad4BP/SF-1 corre- lates with the distribution of P450s in steroidogenic tis- sues such as the adrenal cortex and gonad. In humans, Ad4BP/SF-1 immunoreactivity is observed in not only the normal pituitary, adrenal, ovary and testis, but also in its disorders [2, 7, 10, 11]. With regard to the target genes of Ad4BP/SF-1, genes functionally related to ste- roidogenesis, such as P450(CYP) steroid hydroxylase, 3ß- hydroxysteroid dehydrogenase (3ß-HSD), and steroido- genic acute regulatory protein (StAR) genes, have been identified [20]. Gene disruption studies indicated the im- portant role of Ad4BP/SF-1 in the differentiation of ste- roidogenic tissues by demonstrating developmental defi- cits of such tissues in affected animals [19].
Sasano et al. [9] reported in their immunohistochem- ical study that Ad4BP/SF-1 immunoreactivity was pres- ent in the nuclei of nearly all adrenocortical parenchymal cells in both normal and pathological human adrenal tumors, including adenoma and carcinoma. They dem- onstrated its immunoreactivity in more than 90% of car- cinoma cells in the 5 cases examined. In our cases, how- ever, 2 of 4 patients did not have Ad4BP/SF-1 immunore- activity; therefore, we also examined the expression of DAX-1, which is another transcription factor implicated in steroidogenesis in adrenocortical carcinoma.
DAX-1 binds DNA, acts as a transcriptional repressor of other nuclear hormone receptors, and colocalizes with Ad4BP/SF-1 inhibiting Ad4BP/SF-1-mediated transacti- vation of target genes in steroidogenic tissue in the devel- opmental stage of mice [21-23]. Mutations in the DAX-1 gene cause the X-linked cytomegalic form of AHC in males, and affected patients suffer from adrenal insuffi- ciency associated with hypogonadotropic hypogonadism [24-26]. Shibata et al. [27] examined the expression of DAX-1 in benign adrenocortical adenoma. In our study, we demonstrated the expression of DAX-1 in adrenocor- tical carcinoma of not only the primary site but also the metastatic site using biopsy specimens. This may be use- ful to diagnose adrenocortical carcinoma, especially in Ad4BP/SF-1-negative cases. Contrasting expression pro- files between the expression of CYP17, encoding a key enzyme in glucocorticoid and adrenal androgen produc- tion, and DAX-1 were reported in cortisol-producing ad- enomas causing Cushing syndrome and deoxycorticoste- rone-producing adenomas [27]. In our study, patients with adrenocortical carcinoma had normal hormonal findings because the high expression of DAX-1 in adre- nocortical carcinoma may repress CYP17 gene transcrip- tion.
The most frequent metastatic sites of primary adreno- cortical carcinoma are the lung, liver and bone [10], how- ever the incidence of metastatic tumor involving the ad- renal glands is much higher than the incidence of pri- mary adenocarcinoma. When adrenocortical carcinoma metastasizes to other organs, the primary malignancy of that organ needs to be considered. When adrenocortical carcinoma metastasizes to bone, soft tissue or lymph nodes, the differential diagnosis should include metastat- ic carcinoma, sarcoma and melanoma of other sources [13]. Patient 2 in our study was initially suspected as hav- ing bone cancer by an orthopedist and underwent a nee- dle biopsy for iliac tumor. Since it was difficult to distin- guish from adrenocortical carcinoma pathohistological- ly, we performed the immunohistochemical study using Ad4BP/SF-1 and DAX-1 antibody and succeeded in diag- nosing a metastatic site of adrenocortical carcinoma. Ad4BP/SF-1 and DAX-1 are very useful immunohisto- chemical markers in diagnosing the origin of metastatic sites of adrenocortical carcinoma.
Conclusions
Our results indicate that the expressions of Ad4BP/ SF-1 and DAX-1 are essential for maintenance of the bio- logical characteristics of adrenocortical cells even with- out abnormal hormonal findings or even after malignant transformation and metastasis. Ad4BP/SF-1 and DAX-1 can be additional immunohistologic markers to diagnose adrenocortical carcinoma. Although Ad4BP/SF-1 and DAX-1 are expressed not only in benign adrenal adeno- ma but also malignant adrenocortical carcinoma, it is useful to distinguish from other retroperitoneal tumors, especially in patients with bulky tumors, and to diagnose the origin of the metastatic site as adrenocortical carci- noma in patients clinically presenting with widespread metastasis.
Acknowledgments
We thank Professor Ken-ichiro Morohashi (Division of Sex Differentiation, National Institute for Basic Biology) for the gen- erous gift of Ad4BP/SF-1 and DAX-1 antibodies.
This research was supported in part by Grants-in-Aid 18591768 and18689039 from the Japanese Ministry of Education, Culture, Science and Technology.
References
1 Roman S: Adrenocortical carcinoma. Curr Opin Oncol 2006;18:36-42.
2 Sasano H, Shizawa S, Suzuki T, Takayama K, Fukaya T, Morohashi K, Nagura H: Tran- scription factor adrenal-4 binding protein as a marker of adrenocortical malignancy. Hum Pathol 1995;26:1154-1156.
3 Weiss LM: Comparative histologic study of 43 metastasizing and nonmetastasizing ad- renocortical tumors. Am J Surg Pathol 1984; 8:163-169.
4 Cohn K, Gottesman L, Brennan M: Adreno- cortical carcinoma. Surgery 1986;100:1170- 1177.
5 Hough AJ, Hollifield JW, Page DL, Hart- mann WH: Prognostic factors in adrenal cortical tumors. A mathematical analysis of clinical and morphologic data. Am J Clin Pathol 1979;72:390-399.
6 Suzuki T, Mizusaki H, Kawabe K, Kasahara M, Yoshioka H, Morohashi K: Concerted regulation of gonad differentiation by tran- scription factors and growth factors. Novar- tis Found Symp 2002;244:68-77.
7 Ikuyama S, Ohe K, Sakai Y, Nakagaki H, Fu- kushima T, Kato Y, Morohashi K, Takay- anagi R, Nawata H: Follicle-stimulating hor- mone ß-subunit gene is expressed in parallel with a transcription factor Ad4BP/SF-1 in human pituitary adenomas. Clin Endocrinol 1996;45:187-193.
8 Ikuyama S, Mu YM, Ohe K, Nakagaki H, Fu- kushima T, Takayanagi R, Nawata H: Ex- pression of an orphan nuclear receptor DAX-1 in human pituitary adenomas. Clin Endocrinol 1998;48:647-654.
9 Sasano H, Shizawa S, Suzuki T, Takayama K, Fukaya T, Morohashi K, Nagura H: Ad4BP in the human adrenal cortex and its disor- ders. J Clin Endocrinol Metab 1995;80:2378- 2380.
10 Takayama K, Sasano H, Fukaya T, Moro- hashi K, Suzuki T, Tamura M, Costa MJ, Ya- jima A: Immunohistochemical localization of Ad4-binding protein with correlation to steroidogenic enzyme expression in cycling human ovaries and sex cord stromal tumors. J Clin Endocrinol Metab 1995;80:2815- 2821.
11 Kojima Y, Sasaki S, Hayashi Y, Umemoto Y, Morohashi K, Kohri K: Role of transcription factors Ad4bp/SF-1 and DAX-1 in steroido- genesis and spermatogenesis in human tes- ticular development and idiopathic azo- ospermia. Int J Urol 2006;13:785-793.
12 Ng L, Libertino JM: Adrenocortical carcino- ma: diagnosis, evaluation and treatment. J Urol 2003;169:5-11.
13 Ren R, Guo M, Sneige N, Moran CA, Gong Y: Fine-needle aspiration of adrenal cortical carcinoma: cytologic spectrum and diagnos- tic challenges. Am J Clin Pathol 2006;126: 389-398.
14 Sasano H, Suzuki T, Nagura H, Nishikawa T: Steroidogenesis in human adrenocortical carcinoma: biochemical activities, immuno- histochemistry, and in situ hybridization of steroidogenic enzymes and histopathologic study in nine cases. Hum Pathol 1993;24: 397-404.
15 Tupikowski W, Bednarek G, Florek A: Adre- nocortical carcinoma and its treatment. Postepy Hig Med Dosw 2004;58:27-36.
16 Bodie B, Novick AC, Pontes JE, Straffon RA, Montie JE, Babiak T, Sheeler L, Schumacher P: The Cleveland Clinic experience with ad- renal cortical carcinoma. J Urol 1989;141: 257-260.
17 Kasperlik-Zaluska AA, Migdalska B, Ma- kowska A: Impact of adjuvant mitotane on the clinical course of patients with adreno- cortical cancer. Cancer 1994;73:1533-1535.
18 Wajchenberg BL, Albergaria Pereira MA, Medonca BB, Latronico AC, Campos Car- neiro P, Alves VA, Zerbini MC, Liberman B, Carlos Gomes G, Kirschner MA: Adreno- cortical carcinoma: clinical and laboratory observations. Cancer 2000;88:711-736.
19 Luo X, Ikeda Y, Parker KL: A cell-specific nuclear receptor is essential for adrenal and gonadal development and sexual differentia- tion. Cell 1994;77:481-490.
20 Morohashi K: Gonadal and extragonadal functions of Ad4BP/SF-1: Developmental as- pects. Trends Endocrinol Metab 1999;10: 169-173.
21 Ikeda Y, Swain A, Weber TJ, Hentges KE, Zanaria E, Lalli E, Tamai KT, Sassone-Corsi P, Lovell-Badge R, Camerino G, Parker KL: Steroidogenic factor 1 and Dax-1 colocalize in multiple cell lineages: potential links in endocrine development. Mol Endocrinol 1996;10:1261-1272.
22 Lalli E, Sassone-Corsi P: DAX-1, an unusual orphan receptor at the crossroads of ste- roidogenic function and sexual differentia- tion. Mol Endocrinol 2003;17:1445-1453.
23 Hanley NA, Rainey WE, Wilson DI, Ball SG, Parker KL: Expression profiles of SF-1, DAX1, and CYP17 in the human fetal adre- nal gland: potential interactions in gene reg- ulation. Mol Endocrinol 2001;15:57-68.
24 Zanaria E, Muscatelli F, Bardoni B, Strom TM, Guioli S, Guo W, Lalli E, Moser C, Walker AP, McCabe ER: An unusual mem- ber of the nuclear hormone receptor super- family responsible for X-linked adrenal hy- poplasia congenita. Nature 1994;372:635- 641.
25 Muscatelli F, Strom TM, Walker AP, Zanaria E, Recan D, Meindl A, Bardoni B, Guioli S, Zehetner G, Rabl W, Schwarz HP, Kaplan JC, Camerino G, Meitinger T, Monaco AP: Mu- tations in the DAX-1 gene give rise to both X-linked adrenal hypoplasia congenita and hypogonadotropic hypogonadism. Nature 1994;372:672-676.
26 Ahmad I, Paterson WF, Lin L, Adlard P, Duncan P, Tolmie J, Achermann JC, Donald- son MD: A novel missense mutation in DAX- 1 with an unusual presentation of X-linked adrenal hypoplasia congenita. Horm Res 2007;68:32-37.
27 Shibata H, Ikeda Y, Mukai T, Morohashi K, Kurihara I, Ando T, Suzuki T, Kobayashi S, Murai M, Saito I, Saruta T: Expression pro- files of COUP-TF, DAX-1, and SF-1 in the human adrenal gland and adrenocortical tu- mors: possible implications in steroidogen- esis. Mol Genet Metab 2001;74:206-216.
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